Inactive (722)

Segment Number 1
Audio File corona/1638cr1a.mp3
Doctors Mudge, Bradley P.
Featured Speaker Bradley P. Mudge, MD
Guest Bio Dr. Bradley Mudge a board certified plastic surgeon performs an array of cosmetic and reconstructive procedures at his state of the art of facility in Newport Beach California. Novare Plastic Surgery & Skin Care Center and Orange Coast Surgical Center is located just inside Fashion Island Newport Center allowing patients the comfort and ease of being treated in an exclusive private setting. The facilities beauty, convenience along with the JACHO Accredited Ambulatory Surgical Center truly sets it apart from the rest. Whether you're a new or a returning patient we ask that you take a look at all of the procedures we offer and call any of our friendly staff to learn more. Cosmetic and follow appointments are also available at any of our three convenient dermatology offices.
Transcription Melanie Cole (Host): You may have had or are about to have a mastectomy. Either you’ve been diagnosed with breast cancer or are at a very high risk of developing it in the future. If so, your doctor may have told you about options to rebuild your breast or breasts, a surgery called “breast reconstruction”. My guest today is Dr. Bradley Mudge. He’s a board certified plastic surgeon and a member of the medical staff at Corona Regional Medical Center. Welcome to the show, Dr. Mudge. I’d just like to start by asking you, what do you tell women every day about breast reconstruction if they’re also going through cancer treatment?

Dr. Bradley Mudge (Guest): Well, the conversation about breast reconstruction is fairly lengthy and based upon their previous education and what research they’ve done themselves, but I like to stress that the choice for reconstruction is a personal choice and entirely up to them. There are many options that we can help people with so that the process has to be tailored to their expectations, their desired outcomes, their available down time and so forth. But, I do like to stress that it’s an opportunity to make themselves a little more whole again after a fairly emotionally and physically disfiguring surgery and a chance to get back something that they would’ve lost otherwise.

Melanie: Let’s discuss some of those breast reconstruction options that you mentioned. What options does a woman have if she knows she’s either having prophylactic mastectomy because she’s been found to have the genetic link, or because she’s just gone through cancer treatment?

Dr. Mudge: Reconstruction can roughly be divided into two broad categories: that being using your own tissue or using an implant, and there is a hybrid of those two categories as well which works well for some people. The final choice on what a woman will decide upon depends a lot on her body habitus, her smoking history, the extent of her cancer, her available down time, her willingness to have various scars on her body and so forth. Each of those options is available and just requires a fair bit of research with each patient to determine it. Something fairly exciting and another option women have over the past probably 4-5 years, is nipple preservation. Many women electing for elective mastectomy, whether that is for a positive gene testing or painful lumps in their breasts or whatever the cause may be, many of these women will actually elect to preserve their nipple areolar complexes. In addition to that, there’s been a recent trend towards preserving the nipple areolar complex in someone who actually has cancer, and that’s kind of an exciting option for those who meet the necessary criteria.

Melanie: How do they decide between immediate or delayed breast reconstruction?

Dr. Mudge: That will depend a lot on how aggressive their tumor is, sometimes the urgency of it and the timing with the general surgeon. If there is a plastic surgeon and a general surgeon willing to do both at the same time, most of the time that’s going to be a better option. It obviously saves the woman from having one more surgery. In addition to that, it alleviates that time when they are totally flat and actually a little bit indented. It kind of takes away some of that emotional stress and fatigue that can come from looking at a fairly disfigured chest. So, we prefer to do it immediately if possible. Something that might change that a little bit on really aggressive tumors where chemo needs to be started as soon as possible in the post op period, we’ll sometimes hold off on that because we don’t want the breast reconstruction to interfere with the urgency of the chemotherapy. There used to be a trend where if you knew you were going to receive radiation therapy, that you would wait to get your breast reconstruction. That’s changed quite a bit over the past decade and now, the thinking is it’s best to go ahead and initiate the reconstructive process with some sort of implant in there and try to stretch the skin out a little bit to help you get that extra skin you’re going to need before the radiation injury is applied to the breast.

Melanie: What types of implants are used for breast reconstruction now?

Dr. Mudge: The most common would be a silicone implant. Probably 95% of women get a silicone implant. In that category, then, we do have an exciting new implant, what we call “highly cohesive implant”, meaning a little bit thicker. So, that’s very useful in the reconstruction for women because after a mastectomy, there’s very little, what we call “subcutaneous tissue” or tissue beneath the skin left, and if you place a normal standard silicone implant in, it can look quite rippled and abnormal. The highly cohesive implants maintain their shape a little better and give an overall better appearance to the breast, although you do sacrifice a little softness to it. Saline implants are another option and, at times we still use those, particularly when a woman wants to be quite large. The silicone implants only come up to 800cc in size, so we’re limited how large we can make those. In those cases, saline is a good option.

Melanie: And, what about breast reconstruction using your own tissue, the flap procedure? Tell us about that.

Dr. Mudge: There’s two basic ways to do that and then there are other variations which are a little more usual. You can use your abdominal tissue. That’s called a “TRAM flap” and sacrifice one of your rectus abdominis muscles or your six-pack muscles and move the abdominal tissue up to the breast and reconstruct it that way. That process has significantly more down time, more scarring and certainly more risks than an implant reconstruction would have. The other thing that’s changing over the past few years in that regard is a lot of women are doing bilateral mastectomy and reconstruction. That number has really increased significantly during the past decade. It would be fairly hard to use both abdominal muscles for that because it leaves you with a fairly weak abdominal wall. That’s the TRAM flap. The other option is the latissimus dorsi flap which is bringing some muscle around from your back with a skin paddle with it and reconstructing the breast mound that way. Typically, unless the woman is looking for a fairly small breast, the latissimus flap method will also require implants to be placed.

Melanie: What changes for screening after this reconstruction? Are they able to have mammograms or is it ultrasound after that? Tell us about that.

Dr. Mudge: That would vary and sort of be left up to the oncologist depending on how aggressive their tumor was and how close the tumor was to the margin. You can still have a mammogram and some women will still get those per their oncologist’s request. The gold standard and probably the best way to look at it would be with an MRI which can not only detect soft tissue changes such as early recurrences or suspicious lesions in the breast but it can also evaluate the integrity of the implant itself and give you an idea if the implant could be ruptured.

Melanie: Does the implant have to be replaced at some point?

Dr. Mudge: The common thinking is that implants should be replaced every 10 years. In the world of cosmetic surgery, that’s not an absolute requirement because you will notice when it’s ruptured. Your mammogram will show it and there’s no urgency to get them replaced. In the world of reconstruction, it’s a little more complicating and, in general, I would recommend a reconstructive patient have re-implants, change that every 10 years just to prevent that rupture which can be a lot more destructive in a reconstructed patient as compared to a cosmetic patient. That’s not to say that the leaking silicone is causing problems with the rest of your body such as chronic fatigue, lupus and things we used to worry about. That’s all been disproven, but the reason for not wanting a rupture in a reconstructed patient is because there’s so very little soft tissue left, by the time you clean out that ruptured silicone, you’re going to have very, very thin flaps and tissue left which will hamper the aesthetic result.

Melanie: Will they have feeling in the reconstructed breast?

Dr. Mudge: If the nipple areolar complex is preserved, it will have essentially no feeling. You might have a small bit of feeling at best but the main nerve that runs through the breast to give sensation to the nipple would have been removed during a mastectomy. If they have sacrificed their nipple areolar complex and are left just a transverse or a crossways running scar, the feeling is very limited in the area. Much after any surgery, such as a facelift or tummy tuck, there’s very little feeling around the scar. Some of the feeling comes back as the years go by which is a good thing because areas in your body that are numb are not great because they can be subject to burn or pressure or freezing, things like that, but essentially they won’t have a lot of feeling over the breast, especially the central portion of the breast.

Melanie: And, how will aging affect that breast?

Dr. Mudge: Well, the good news is that, in general, with an implant reconstruction and the artificial skin sling that we placed in the inside, there’s very little drooping of the breast as the years go by. They stay up and in high and appropriate position and shouldn’t move much at all. Anyone will undergo the typical skin changes such as thinning and perhaps age spots and wrinkles on the breast tissue but the implants themselves and, thus, the breast mound should not descend down the chest wall much at all.

Melanie: And, in just the last few minutes, Dr. Mudge, what should people that may have to have a mastectomy think about when seeking care? What should they look for?

Dr. Mudge: With regard to the mastectomy itself, that would be something a general surgeon would discuss with them. I would encourage everyone who is thinking about or needing a mastectomy to at least request to speak with a plastic surgeon so they can get input and see what their options are. Breast reconstruction isn’t going to be for everyone but a woman should know that it’s available if she wants it and be allowed to discuss her options with a knowledgeable professional.

Melanie: And, why should they come to Corona Regional Medical Center for their care?

Dr. Mudge: I think Corona Regional Medical Center has a uniquely efficient operating room. The anesthesiology staff is excellent. Their operating room is spacious and it’s just a very pleasant place to work. I’m speaking as a surgeon now. The hospital is going through a lot of changes and improvements which are making the rooms upstairs where you’ll spend one to two nights much more pleasant and friendly for your family and just a variety of other structural and logistical changes in the hospital make the service there quite excellent.

Melanie: Thank you so much for being with us today, Dr. Mudge. You’re listening to Corona Regional Radio with Corona Regional Medical Center. For more information, you can go to CoronaRegional.com. That’s CoronaRegional.com. Physicians are independent practitioners who are not employees or agents of Corona Regional Medical Center. The hospital shall not be liable for actions or treatments provided by physicians. This is Melanie Cole, thanks so much for listening.
Hosts Melanie Cole, MS

From Incontinence to Prolapse and Back Again: the ABC's of Pelvic Floor Survivorship

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Segment Number 3
Audio File city_hope/1637ch2c.mp3
Doctors Cohen, Seth A.
Featured Speaker Seth A. Cohen, MD
Guest Bio Seth A. Cohen, M.D., joined City of Hope in 2016 as a urologist specializing in complex reconstruction of the pelvic floor, including fistula and pelvic organ prolapse repair. Dr. Cohen received his medical doctorate and Bachelor of Arts degrees at Northwestern University through the prestigious Honors Program in Medical Education, which allowed for direct matriculation into medical school after three years of undergraduate work. He completed his post-graduate training in California, including an internship in the Department of Surgery at University of California, San Francisco, a residency in urology at University of California, San Diego and a fellowship in Female Pelvic Medicine and Reconstructive Surgery at University of California, Los Angeles. Dr. Cohen has published in a variety of medical journals on topics including mesh-associated complications, robotic cystectomy and radiation exposure during lithotripsy.

Learn more about Seth A. Cohen, MD
Transcription Melanie Cole (Host): Women with cancers in the pelvic region such as cervical cancer, bladder cancer or uterine cancer may often have problems with incontinence and although this is sometimes difficult to discuss, it's a very important part of recovery. My guest today is Dr. Seth Cohen. He's a urogynecologist at City of Hope. Welcome to the show, Dr. Cohen. So, what type of cancers predispose a woman to incontinence and/or pelvic prolapse?

Dr. Seth Cohen (Guest): Sure, Melanie. Thanks, for having me on the show. I think it's important to note that everything you just said is exactly right. Any sort of pelvic floor malignancy, whether it's cervical cancer, uterine cancer, ovarian cancer or a non-disclosed tumor that impacts those tissue spaces, can lead to some sort of prolapse or incontinence. Really, that happens after the primary treatment for cancer. So, these are issues that tend to arise after someone has been treated for cancer, usually in the setting of some sort of surgery where tissue is removed. Now this also can occur in situations where people have had chemotherapy or radiation to that pelvic floor area because that also damages the tissues. I think it's also important to note, though, that any sort of systemic treatment for cancer, whether it's chemotherapy or radiation--any sort of systemic treatment--can really impact nerves as well and tissues in ways that we don't even know. So, any sort of cancer treatment really can ultimately result in some sort of sequelae for the pelvic floor where women might see some incontinence or prolapse.

Melanie: Women hear about pelvic floor muscles and incontinence more often in the media but what is pelvic organ prolapse? They don't seem to hear about this quite as much.

Dr. Cohen: Sure. This is probably our fault as providers. This is a terminology we use to communicate but forget that the people at large, why would they understand this? And, really, it's a hernia. That's what we're talking about. It's a hernia of the pelvic floor. The vagina, for all intents and purposes is a potential space and when tissues fall and there’s laxity in the pelvic floor, like any potential space, that area is filled. So, it's a hernia of the vaginal canal.

Melanie: So, what would that mean for the women? What would they experience if they have a hernia of the vaginal canal?

Dr. Cohen: Common symptoms for women who experience it are pressure, discomfort. Usually, they'll be walking and they often describe they almost feel like something is going to fall out of their vagina almost like a sensation of giving birth without the pain, for all intents and purposes. And, not only can it be discomforting during ambulation, it could also be discomforting during intercourse. It could be discomforting when you're doing any sort of heavy lifting; if you're at the store buying groceries. Any way that you can manifest by creating pressure in your thoracic cavity and the abdomen, that will translate down to the pelvic floor and push those tissues out.

Melanie: Are there different types of prolapse? And, are there ways to manage them that we could do without necessarily going through intervention?

Dr. Cohen: For sure. So, there are different types of prolapse and, once again, that tends to be nomenclature and terminology we use as providers to talk. But, if you imagine the vagina as three compartments: so, the anterior compartment; the apical compartment, which is the top or cap of vagina; and then, the posterior compartment. Any of those walls can fall in. So, it's like a three-walled room. At any given time, one of those walls can fall into the other and we describe that as either anterior prolapse, apical prolapse or posterior prolapse. And, really, those are pseudonyms for the structures behind those walls. So, in front of the vagina, the anterior wall, is the bladder. For the cap or the apical part of the vagina, that's the uterus and the cervix. And then, for the posterior part of the vagina, that's the rectum. When we are talking about anterior, posterior, apical prolapse, really what we're saying is, this part of the vaginal wall is falling in and most likely behind it are these other organ contents that are precipitating that. There are many ways to treat pelvical prolapse. This is not a life ending disease, thank goodness. This is a life altering disease process. If someone is at a stage in their life, if they are very elderly and they really just want to be comfortable and they are not interested in undergoing a surgical operation, there is something called a “pessary”, which is a malleable, soft piece of plastic that we insert into the vaginal canal. There are many different pessaries but the most common one looks like a disc, almost like a Frisbee and it raises or elevates those soft tissues, so that when you are ambulating or lifting, those tissues aren't herniating and falling down into the vagina. Tt works quite well. Unfortunately, a lot of women just don't want to do that because it can be uncomfortable in sexual and personal life, but for those that don't want to undergo surgery, that is certainly an option.

Melanie: And so, the pessary, is that something that once inserted, stays in there?

Dr. Cohen: We do ask that women either learn how to change it themselves or they come back to our office and we will help them change it approximately every 6-8 weeks. There can be more vaginal discharge with the pessary in place than there would be otherwise. Typically, we'll also ask them to use a topical solution to help maintain a PH balance within the vaginal canal when they have the pessary in or perhaps an estrogen cream itself. But, usually, it's pretty low maintenance therapy.

Melanie: And so, when we're combining this with incontinence, which as I said in my intro, it's difficult for women to discuss but you see these commercials and such. What kind of interventions, Dr. Cohen, can you do to address these issues with women when they come to you?

Dr. Cohen: Sure. I think the most important thing to note is that this shouldn't be a topic in the dark. This is a quality of life issue and in today's day and age, you shouldn't have to limit yourself. We ask that you seek help. We want to help. That's why we're here. We have a great team at City of Hope that's very invested in making this as nice a process, as easy a process as possible. But, to go back to your question, the interventions are myriad. If it's everything from just plain old incontinence, we could do slings or hammocks to essentially restore outward resistance to the urethra. The urethra is a faucet. When the faucet's washer breaks, you have to replace the washer. Now, we can't exactly replace the washer but we can do a lot of things to reinforce the continence mechanism or the resistance of the urethra and improve that and then decrease the amount of leakage that occurs. If someone's having prolapse and incontinence at the same time, we can usually do procedures where we address both. It's all an issue of restoring anatomical support. We can do a vaginal surgery for prolapse where everything is done through the vaginal canal itself. We also can do robotic surgery now for prolapse which has been a well-documented operation with robotic assistance, sacrocolpopexy, provides a mesh augment placed through the abdomen, not through the vagina, to support the anterior, posterior vaginal wall and really elevate that whole vaginal canal towards the sacrum, and attach is to a ligament over the sacrum itself, a very strong ligament. Really, it's meant to fix the top of the vagina falling. We are noticing that a lot of people are using it now to fix multi-compartment prolapse. If you need to, you can always go back down below and do additional vaginal reconstruction for the prolapse at the same time.

Melanie: Are there certain things women can do, lifestyle modifications, that can help them? We hear about Kegel exercises and maintaining that good strong pelvic floor. What do you tell women about that?

Dr. Cohen: I tell women conservative therapy is always what I like to start with. If there is a woman who is willing to go through the rigors of pelvic floor physical therapy, and I say that because good pelvic floor physical therapy is not easy. It's not an easy process. You've got to go every week. You've got to use muscles you've never used before. It's a workout. You really also got to have access to someone who knows what they are doing. You got to have a good pelvic floor physical therapist working with you to make sure that you are getting the appropriate treatments. If you're willing to do that, if you're willing to go to the sessions, if you're willing to do the exercises at home, some women do find benefits, especially in the realm of incontinence. That can be very helpful. So, I would encourage women to seek that out as long as they're getting the right care and they're actually diligent about going to those sessions.

Melanie: Is there anything else they can do that would contribute? Weight loss or nutritionally or smoking. Do any of those things have to do with this?

Dr. Cohen: For sure. Overall health wellness is something that cannot be understated. Like everything else in your life, no tobacco, weight loss, eating healthy, these are all things that not only impact your bowel movements, your pelvic floor health and may impact your overall health, no doubt, weight loss will improve and lessen your incontinence and decrease the prolapse burden you are seeing. No doubt that smoking less will actually improve outcomes after surgery. We know that women that smoke, if they undergo sacrocolpopexy, they have a higher rate of mesh extrusion over time in the vaginal wall, which is something we do not want to happen. So, no doubt, living a healthy lifestyle cannot be understated as something that could possibly impact your pelvic floor health.

Melanie: So, wrap it up for us, Dr. Cohen. It's really great information and such an important topic for women to hear. So, wrap up from incontinence to prolapse and back again, the ABCs. of pelvic floor survivorship following cancer treatments.

Dr. Cohen: Sure. I think, number one: cancer is a process that devastates. If you make it through that, if we can help you, if we can beat the cancer back, that's City of Hope's primary goal and they do a fantastic job of it. But, the journey doesn't end there. Once you've finished that, if you're having issues with incontinence, with prolapse, with bladder dysfunction, with fecal incontinence, you should not have to live with these battle scars. We are out there to help you. We are out there to make your life better whether it's through conservative therapies, whether it's through surgical endeavors, there is a very, very good team here at City of Hope that would rival anywhere else in the country composed of myself, Dr. Jonathan Warner and Dr. Christopher Chang, as the pelvic reconstructive faculty. I think the three of us, with all of us here, amongst us, we could probably tackle anything. I truly believe that. And, so, we would encourage you to seek out help .We're here and we would love you to come here and let us give you our insight into whatever we can provide.

Melanie: Thank you so much for being with us today. You're listening to City of Hope Radio and for more information, you can go to www.cityofhope.org. That's www.cityofhope.org. This is Melanie Cole. Thanks so much for listening.
Internal Notes incon
Hosts Melanie Cole, MS

Nail Insertion to Address Limb Length Discrepancy

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Segment Number 3
Audio File virginia_health/1635vh4c.mp3
Doctors Romness, Mark
Featured Speaker Mark J Romness, MD
Guest Bio Dr. Mark Romness is an orthopedic surgeon who focuses on the treatment of children with musculoskeletal problems and the effectiveness of those treatments.

Learn more about Dr. Mark Romness

Learn more about UVA Children’s Hospital
Transcription Melanie Cole (Host): At UVA Children's Hospital, orthopedic surgeons encounter a variety of congenital conditions that affect a child's mobility and they stay abreast of the latest technologies and procedures to provide patients with greater options. My guest today is Dr. Mark Romness. He's an orthopedic surgeon who focuses on the treatment of children with musculoskeletal problems at UVA Health System. Welcome to the show, Dr. Romness. What is leg or limb length discrepancy?

Dr. Mark Romness (Guest): Limb length discrepancy is really a fancy medical term for unequal leg length or someone that just has one leg that's longer or shorter than the other one. That can be from multiple causes. Sometimes, there are even some birth conditions where one leg doesn't grow as rapidly as the other. The other area we usually see it is from previous trauma or injury to the child's growth plate in the bone leading to growth abnormalities in the bone and that ends up in one leg being either longer or shorter than the other leg.

Melanie: Is this something that's very obvious or would the child start to experience some pain in walking, or can you just really see it?

Dr. Romness: It's usually not painful and it can often start out as something very subtle, which is maybe a quarter or a half inch difference in their length but as the child grows, that discrepancy or difference in leg length can get worse and so it's fairly related to the age of the child. So, the younger the child it's more hidden, but it's also a higher risk in chance that it might cause more problems down the road.

Melanie: If someone comes to you and their child has this discrepancy, do you start with things like you know, lifts for their leg or for their other foot or do you go right to some interventions?

Dr. Romness: Generally, a lift is not absolutely required. Everybody thinks that having a little bit of difference in leg length is going to affect your legs, your hips, your spine, cause back pain, but there's really no data to support that. And, the other thing is, just small differences don't make that big of an effect, mainly because we're rarely standing on both legs at the same time. But, it's really the more dramatic differences--once you get up to closer to an inch or more--that you'll actually start to see a significant limp. It can also even affect your energy efficiency walking once you get up to about one or two inch difference.

Melanie: Are there some complications from not addressing this issue?

Dr. Romness: I mean, again, shorter or smaller length differences can be compensated just by the body or with a simple lift in the shoe, but once you get up over an inch or once you get into the two to three inch range, then it really throws off the dynamics of the body and you're better off addressing it with more equalization procedures.

Melanie: So, tell us about some of those equalization procedures--the PRECICE® nail insertion.

Dr. Romness: Sure. When you're dealing with two legs that are unequal, I often simplify it and say that you can either shorten the long leg or lengthen the short leg. In a growing child, sometimes we can have the leg stop growing early so that the other leg can catch up, but the other way to do it is to lengthen the short leg. The way we do that is make a cut in the bone and gradually separate the bone at about a millimeter a day. Traditionally, that's been done with sort of external fixation, or ring devices on the outside of the leg but, more recently, there's been a new technology where you can actually lengthen with a rod that goes down the inside of the bone and that way nothing is outside.

Melanie: So, tell us about that procedure. So, this is a surgical procedure for a child. Is it something that stays in permanently? Is it temporary? Tell us about it.

Dr. Romness: The rod itself goes down the middle of the bone. It's usually only for sort of the older kids that are close to done growing, but it's an excellent internal device that you can control the lengthening carefully with. Once the bone is out to length and healed, we usually do recommend that the rod come out, just because if it stays in there too long, it can be very difficult to get out.

Melanie: So, you can actually control this rod from outside the body as this child grows? I don't mean to be simplistic, but something like braces in a child's mouth that changes their jaw structure. Is that what this is like?

Dr. Romness: It's similar. Again, it's a rod that's distracted using magnets. So, you have an external drive device that the patient positions on his or her leg and they can control how much the rod distracts. We usually do three distractions a day at a third of a millimeter a day, so you're actually lengthening the bone at one millimeter per day.

Melanie: Is this painful for the child?

Dr. Romness: In general, no. You know, with a simple straightforward distraction, it's relatively pain-free after you're over the initial surgical procedure. It's partly because the distractions are so small. You're looking at one-third of a millimeter per distraction, so the stretch on the leg is usually not that painful.

Melanie: Do they have a problem going through security in airports? What is it made of?

Dr. Romness: I don't know the exact metal, but because it's deep and implanted, it rarely sets off metal detectors.

Melanie: Wow. That's fascinating. How long do you leave it in?

Dr. Romness: It's usually about a year or two until it's taken out. The lengthening process takes, again, as I mentioned, you're actually lengthening it one millimeter per day, but then you also have to wait for that bone to heal, which takes a little bit longer. On average, a true healing is about one month per centimeter of lengthening. So, if you're looking at an inch of length, that's about two-and-a-half to three months until the bone is well-formed and strong.

Melanie: So, when the child is done using this device, then the ossification of their bones, is that affected? When you take this out, what goes on inside their bones? Are they still able to grow?

Dr. Romness: Yes, because during the lengthening procedure, you're lengthening toward the middle of the bone, whereas most of the growth comes from the ends of the bone.

Melanie: That's absolutely fascinating. Are there any drawback to it?

Dr. Romness: I mean, with the lengthening procedure, you are concerned about developing contractures in the joints above and below the bone, so that does need to be monitored carefully during the lengthening process. You also have to be careful with your lengthening rate, that if you lengthen too quickly, you'll stretch all the surrounding soft tissues, including the nerves and blood vessels whereas if you lengthen too slow, the bone will form too quickly and then it will actually heal too quickly and you won't be able to keep lengthening.

Melanie: The surrounding soft tissue was going to be my next question, Dr. Romness, so you answered that. Tell us about some stories and the effectiveness of these treatments--the patients that you've helped that would benefit from this approach. Are they older? Teenagers? Tell us about and give us some of your examples.

Dr. Romness: For this procedure, they need to be close to done growing, so it's usually a teenager where the bone is nearly done growing for the rod, but you can still do lengthening procedures with the external device on the younger kids. The case I think of most is a kid who has been through two lengthenings. He went through one lengthening with the external rings and then, more recently, he went through a lengthening with the internal rod and both the patient and his mother were just ecstatic about how much easier it was the second time.

Melanie: And, what is the child's life like with this device inserted? Are they banned from athletics? Do they have trouble walking? What goes on there?

Dr. Romness: Well, during the initial healing phase, the first week or two, they are on limited activity. It's kind of like when you break your bone, they have to take it easy on it. During the distraction phase they have to be somewhat careful, so we keep them out of sports, but they're able to go to school. And then once the bone is fully healed, it's back to all activities.

Melanie: So, wrap it up for us, Dr. Romness. What an interesting topic this is--about the PRECICE® nail insertion to address limb length discrepancy. Tell people listening what you really want them to know and why they should come to UVA Health System for their care.

Dr. Romness: Well, I think it's an excellent opportunity for state-of-the-art technology and I think UVA has been good at keeping ahead of pace with this type of activity and keeping what's best for the patient in mind.

Melanie: Thank you so much for being with us today, Dr. Romness. We'd love to have you on the show again. You're listening to UVA Health Systems Radio. For information, you can go to www.UVAhealth.com. That's www.UVAhealth.com. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Do You Suffer from Pelvic Pain?

Additional Info

Segment Number 3
Audio File corona/1634cr5c.mp3
Doctors Koning, Lawrence
Featured Speaker Lawrence Koning, MD
Guest Bio Dr. Koning specializes in Obstetrics & Gynecology and is a member of the medical staff at Corona Regional Medical Center.
Transcription Melanie Cole (Host): There are many changes that can occur in a woman's body during the course of her life that may result in heavy bleeding or pelvic pain. My guest today is Dr. Lawrence Koning. He specializes in obstetrics and gynecology and is a member of the medical staff at Corona Regional medical Center. Welcome to the show, Dr. Koning. What are some reasons a woman might have pelvic pain or heavy bleeding?

Dr. Lawrence Koning (Guest): Well, there are a lot of reasons women have pelvic pain. More commonly, though, is that they have heavy bleeding. Most women do, to be honest, hate their periods, so there are a number of ways to treat that, but pelvic pain can be caused from endometriosis; it could be caused from tumors such as fibroids, or just basically heavy periods, which is very common.

Melanie: So, how would we know that this pelvic pain--when do we go see a doctor if we are suffering, because, sometimes hormone levels or things can cause pain in the pelvis.

Dr. Koning: Well, almost all women will occasionally have a heavy period or pelvic pain and cramping with their period, but if they start having increasing pain, or certainly if their periods are longer than usual--more than four to five to seven days--and they're having clotting and changing their feminine hygiene more than every one or two hours, certainly that's the time to go see the gynecologist.

Melanie: What would be the first line of defense if a woman did come to you and say she has pelvic pain or heavy bleeding?

Dr. Koning: Well, the most important thing is to get a complete history and physical. Of course, it depends on the woman's age and what her childbearing desires are--if she's already had kids or wants more kids, those are certainly important things depending on what all of her symptoms are. If they have pelvic pain and they're very young, they can usually--of course, they need an ultrasound, a physical exam, more of a history to determine how long the pain has been going on, if it's related to various things and activities they're doing, such as sexual intercourse or other activities. Or, if it's just mild pain and cramping with their periods, then that can be much less serious, but certainly the first step is to get an appointment with some gynecologist they trust and have an exam and have a history and have some imaging, such as ultrasound, which is very safe, and then go from there and determine what the next choices would be.

Melanie: So, tell us about one of those choices: endometrial ablation. What is that?

Dr. Koning: Well, endometrial ablation is one of my personal favorites because it is so safe and simple. It's a very quick outpatient procedure. The actual procedure takes about 10 minutes and I almost like to liken it to a microwave. It sounds maybe a little unusual to a woman the first time, but rather than having a hysterectomy and, quite honestly, many women don't want to even to go to the gynecologist because they're afraid they'll get rushed to a hysterectomy. I've found if you sit with them and explain how simple the ablation is--it's a very simple outpatient procedure that takes about ten minutes, and it is very effective, and so it's one of our favorites to stop heavy bleeding. They do have to be finished with their childbearing, so it depends on their situation, age and how many kids they have, but it is a very effective procedure.

Melanie: And, if somebody is a candidate for endometrial ablation, what's the procedure like?

Dr. Koning: Oh, it's very simple now. Sometimes we are able to do those in the office but, typically, we'll do those in the hospital. It's a little bit safer that way with the anesthesiologist present. There is light anesthesia where they're sedated, and then they have local anesthesia around the cervix, but the actual procedure is about 8-10 minutes where we take a look inside with a camera inside the uterus and then a device called a “Novasure Endometrial Ablation Device” is placed in there for about typically a minute to a minute-and-a-half and that basically cauterizes the inside lining of the uterus which may sound a little unusual, but it actually very, very safe and the results are very remarkable.

Melanie: What is it like for a woman afterward?

Dr. Koning: There's very little cramping afterwards, maybe for a couple hours, and we give them some pain pills, typically. They can go home just within an hour or two after the procedure and then they may have some little drainage or discharge for up to a week or two, sometimes slight drainage for longer than that, but typically it's sometimes just for a few days.

Melanie: You mentioned when you were speaking about candidates for this procedure, a woman has to be done with her childbearing. Does this have anything to do with perimenopause and getting her ready for that time of life?

Dr. Koning: Well, not necessarily. If they're done with their childbearing and they're sure they don't want to have more children later, then it is an excellent procedure, even if they're younger and theoretically, sometimes the periods can return after five years or longer, but if they're close to menopause, that's even better. The results are even better because they're near menopause anyway, so if you can get some time of two to three to five years, then they can avoid hysterectomy, which is our goal.

Melanie: And then, give us just a little bit wrap up for us of what red flags when a woman is bleeding--because our periods can be heavy and they can be light--when do you recommend this procedure?

Dr. Koning: Yes, if a woman's used to having periods say, four to five to six days, if they're used to that and they start to have either longer periods or changing their feminine hygiene more frequently, or if they're bleeding in between their periods, then they definitely need to have a checkup by a gynecologist to see what's going on and to, of course, rule out cancer, rule out fibroid tumors, and rule out endometriosis and other problems. So, not every woman will be a candidate for an endometrial ablation, but many, many women have had in the past, quite frankly, have had hysterectomies when probably this simple, quick ablation would be much more helpful and much less risky and much less complicated.

Melanie: Does Novasure change the hormones in a woman?

Dr. Koning: No. It really doesn't at all because the ablation is done on the endometrial lining inside the uterus well away from the ovaries, so there's no change in hormones.

Melanie: And, will they still have a period afterward?

Dr. Koning: Probably about half of the women still have some bleeding, but it's much improved, about 95%, have shown by all the research has shown that about 95% of women are very happy with the results, such that they go back to their normal period, or just a spotty, maybe two or three days of spotting rather than the heavy changing tampons and pads every hour and so forth. So, most women are very happy with the procedure.

Melanie: Would they still use birth control after having endometrial ablation?

Dr. Koning: Yes, actually, they still need birth control. So, if their partner has had vasectomy, or if they've had a tubal ligation, or they may still be need to be on other methods of birth control, but endometrial ablation, itself, is not birth control. So, that has to be discussed with their gynecologist prior and then after the procedure to determine what would be best for them.

Melanie: What about sexual relations after this procedure?

Dr. Koning: We usually say about two weeks is average, because there could be some drainage and very, very slight chance of infection. I've never seen an infection after an endometrial ablation. I've probably done over a thousand ablation and there have been no complications. It's a very safe procedure, but to avoid any chance of infection, it would be good to have no relations and we say nothing in the vagina for two weeks.

Melanie: And, in just the last few minutes, Dr. Koning, what should people with pelvic pain or heavy bleeding think about when seeking care?

Dr. Koning: Well, I think they have to find a doctor they trust. Again, I think many women are a little bit fearful of seeing the gynecologist because all they really now about is either strong hormones or a major operation where they're going to be off work for many, many weeks and so forth. So, many women are not even familiar with the concept of going in for a quick, simple procedure that stops their period or improves their bleeding. So, I think they have to, if you will, shop around a little bit and find somebody they trust and go through all the different questions they would have and then they could choose to make the right the decision for themselves.

Melanie: And, why should they come to Corona Regional Medical Center for their care?

Dr. Koning: Well, quite frankly, Corona is a relatively smaller hospital, but it's very good at basic procedures, such as basic gynecologic procedures, such as ablations and procedures such as that and so I think it's an excellent place to go. It's home like and the nurses are excellent and friendly and the facility is excellent. I think they're going to have a good experience there for sure.

Melanie: Thank you so much for being with us today, Dr. Koning. You're listening to Corona Regional Radio with Corona Regional Medical Center. For more information, you can go to CoronaRegional.com. That's CoronaRegional.com. Physicians are individual practitioners who are not employees or agents of Corona Regional Medical Center. The hospital shall not be liable for actions or treatments provided by physicians. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Heated Intraperitoneal Chemotherapy (HIPEC): Treating Difficult Cancers

Additional Info

Segment Number 2
Audio File city_hope/1637ch2b.mp3
Doctors Lee, Byrne
Featured Speaker Byrne Lee, MD
Guest Bio Byrne Lee, M.D., rejoined City of Hope in 2013 with a focus on the treatment of gastrointestinal, pancreatic and liver cancers. He routinely utilizes minimally invasive approaches such as robotic and laparoscopic techniques.

At City of Hope, Dr. Lee leads the surgical team of the peritoneal surface malignancy and heated intraperitoneal chemotherapy program.His expertise in cytoreductive (tumor debulking) surgical procedures has helped our program become one of the most successful in the nation.

Learn more about Byrne Lee, M.D
Transcription Melanie Cole (Host): HIPEC, or heated intraoperative peritoneal chemotherapy, is an alternative method of delivering chemotherapy. Instead of infusing the medications through a vein, the chemotherapy is circulated in the abdominal cavity at the time of surgery. My guest today is Dr. Byrne Lee. He’s the Chief in the Mixed Tumor Surgery Service and Assistant Clinical Professor in the Division of Surgical Oncology at City of Hope. Welcome to the show. Dr. Lee, let’s discuss HIPEC. Tell the listeners what this is versus standard chemotherapy that they’ve heard so much about.

Dr. Byrne Lee (Guest): So, HIPEC is a way of delivering chemotherapy that’s different than the standard way. Essentially when we are dealing with cancers that invade the abdominal cavity, we know that giving chemotherapy by the vein is effective but it’s a hard place for that chemotherapy to sink in and destroy the cancer cells. HIPEC was developed almost 20 years ago and, essentially, the thought was when surgeons are in the operating room, could we help deliver chemotherapy to the cells at hand. So, essentially, when we’re in there and we see the cancer cells floating around, we know that there’s still going to be cancer cells left behind when we’re done with our surgery. Was there a way that we could potentially deliver chemotherapy to be more effective at the site? And, essentially, that’s what it is. When we’re in the operating room, after we’re done with a large surgery to remove abdominal tumors, we place catheters and we infuse the chemotherapy and, again, this is a different way of delivering chemotherapy that allows us to hit the cancer cells at their site of metastasis.

Melanie: Which cancers can be treated with HIPEC, typically?

Dr. Lee: The typical cancers that we see for HIPEC evaluation, those are going to be colon cancers, appendiceal cancers and ovarian cancers. At City of Hope, we do see other cancers that typically metastasize to the abdominal cavity and that’s going to be stomach cancers, mesothelioma, and something called “primary peritoneal cancers”. Certain patients are candidates for HIPEC treatment and we evaluate them for the treatments at City of Hope.

Melanie: So, tell us about the heated part of it because people hear that and they think, “Is like ablation?” Are you burning something? How hot is it? What exactly happens?

Dr. Lee: So, in the operating room, the chemotherapy is heated to about 42 degrees Celsius, that equates to about a temperature of 105 degrees Fahrenheit. The heat does several things. One, we believe that it does kill the cancer cells on hand. Our normal cells have the ability to repair themselves after such a heat shock. Most cancer cells can't repair themselves. So, when they are heated to that temperature, we do see a decline in the numbers and we believe that the cancer cells are actually dying from the heat effect itself. Additionally, chemotherapy will work better when heated, and I think that is the main draw or the main reason why we heat the perfusion because it does allow the chemotherapy to penetrate the cancer cells and be more effective in that way. That’s essentially why we use heat in the operating room.

Melanie: So, does this allow for higher doses of chemotherapy, and is it a one time shot because people think of chemotherapy as coming in once a month, sitting in there for three hours, in the standard form. But, this you’re doing while you’re in the operating room.

Dr. Lee: Correct. And that’s an excellent question. The one time treatment is, that is correct. When we do heated intra-peritoneal chemotherapy, it is a one-time treatment. It basically is done at the time of the debulking surgery and, as I said, the idea is we don’t necessarily do HIPEC unless we know that we have adequately removed all of the abdominal tumors. So, the addition of the large surgery to bring down what we see and then the addition of the HIPEC treatment in the operating room, we believe that that is essential and beneficial to the patient, and that’s a one-time treatment. We do repeat HIPEC treatments when we see return of the cancer. That we have done several times and there are multiple studies out there showing that it can be done safely but, again, it’s in highly selected patients and patients that we know who have benefited from HIPEC in the past, we generally will offer it to them again if we think it’s a reasonable treatment. The question about dosage of chemotherapy. When we perform peritoneal chemotherapy, we can deliver the drug at a higher dose and the reason is because most of that chemotherapy will stay in the abdominal cavity. That’s a benefit because if we were to give these doses through the vein, the side effects would be too much, too toxic. So, when we deliver it in the abdominal cavity, the dosage is going to be higher so the effect in killing cancer cells is going to be higher and the systemic effect is less because less of it will be absorbed.

Melanie: So, there is less side effects. People think of those side effects, Dr. Lee, with chemotherapy and since this done right after cytoreductive surgery and it’s this higher dose that stays in the abdominal cavity, are they going to experience some of those similar side effects--hair loss, nausea--any of those with HIPEC?

Dr. Lee: I don’t see as much of the hair loss that we see with systemic chemotherapy and, generally, I say that that side effect we rarely see with this treatment. The nausea, I do see that and I relate that more to the cytoreductive surgery than the actual chemotherapy or the heat. As we are doing these surgeries, they affect a large amount of the abdominal cavity. We are searching every corner and turning over the abdominal organs in order to visualize where there are potential cancer cells hiding or tumors hiding and that’s what I feel creates quite a bit of nausea in the post-surgery setting. But, the systemic effects such as the drop in the blood count, the hair loss, the fatigue, we don’t see that so much with HIPEC therapy.

Melanie: So, what else would you like them to know about HIPEC therapy, the advantages, and are there any disadvantages?

Dr. Lee: I believe the advantage is this: before we were doing cytoreductive surgery and HIPEC for tumors that metastasized to the abdominal cavity or peritoneal cavity, systemic chemotherapy was not providing a huge survival advantage. In fact, most of these patients were just treated as palliative cases. When we started doing cytoreduction, we did see improvements in survival but they still were not very good. And I think the package, the addition of surgery and chemotherapy in the operating room, has now changed the way we look at this disease. We don’t look at it so much as a terminal disease anymore, we look at it as a potential treatment. Almost like my colleagues that do liver surgery for metastasis, we look at this the same way. We look at it as a metastasis that we can treat and we have effective therapies for these patients at this time.

Melanie: In just the last few minutes, please tell us about your team at City of Hope and this multidisciplinary team of experts, and that you’re one of the busiest HIPEC centers in Southern California. Tell us a little bit about that.

Dr. Lee: City of Hope has always been a special center. We basically are Los Angeles but not in Los Angeles. A lot of our patients do travel quite far, quite a distance, to come and see us. I think one of our strong points is the multidisciplinary team. We have doctors in medical oncology, radiation oncology, surgical oncology and all these experts come together, review each case, and we decide what are the best treatments. Not every patient is going to benefit from HIPEC. Some patients go on to get systemic chemotherapy first and then come back to our team of surgeons. That’s essentially one of the benefits here. It’s as if we can offer many roads, many pathways of therapy and, ultimately, we decide on what’s the best treatment. The surgeons here have great experience in cytoreduction. In fact, the team involves, not only myself but several other surgical oncologists, gynecological oncologists and colorectal surgeons. I think in terms of the team that we’ve put together, we’ve essentially become one of the biggest centers in southern California for HIPEC. I think one of the biggest draws is, again, that we have excellent physicians treating the patients; our outcomes are good; our ability to deliver the treatment safely has helped us gain this center of excellence.

Melanie: Thank you so much for being with us today. What a fascinating topic. You’re listening to City of Hope Radio. For more information, you can go to www.cityofhope.org. That’s www.cityofhope.org. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

How To Deal With Fitness Bullies

Additional Info

Segment Number 1
Audio File allina_health/1637ah3a.mp3
Doctors Paris, Jeannie
Featured Speaker Jeannie Paris, RD, LD -registered dietitian and certified health coach
Guest Bio Jeannie Paris is a registered dietitian and certified health coach who practices with the Penny George Institute for Health and Healing at Unity Hospital in Fridley, Minn., and LiveWell Fitness center at Abbott Northwestern Hospital in Minneapolis, Minn. She is a mother of two teenage boys and enjoys trying new activities to keep herself fit and motivated, like scuba diving, triathlons and hot yoga.

Learn more about Jeannie Paris
Transcription Melanie Cole (Host): Some people purposely try to sabotage your fitness goals because they aren’t having the same success, while others might not even realize that their words or actions are having a negative effect on you and they’ve become a fitness bully. My guest today is Jeannie Paris. She’s a registered dietician and certified health coach who practices with the Penny George Institute for Health and Healing at the LiveWell Fitness Center at Abbot Northwestern Hospital. Welcome to the show, Jeannie. How do you learn to deal with people who try and force poor nutrition on you or poor choices? What do you do with those people?

Jeannie (Guest): Oh, that’s a great question. I come across this quite a bit and I can think of probably several responses to that. The first one is, it’s really okay to say “no”. I understand that this is hard for some people but if you really don’t want to eat it, you don’t have to. A lot of people I think they grew up thinking that their parents taught them if somebody offers you food, you need to accept it, like it’s rude if you don’t. But, as times change and we become adults, we can make our own decisions on what we want to eat and what we don’t. I just really encourage people, if you don’t want it, say “no”. Say, “I could eat it but I really am choosing not to.” Another thing, too, that comes to mind on this is that when people are interested in their health and wellness and they’re wanting to care for their body, even just telling people that “I like my food choices to make me feel good and if I eat cake or if I eat that doughnut, I know it really doesn’t make me feel good”. And then, another thing I think of because sometimes when I talk to people they struggle with saying “no” or being a little bit more upfront. So, sometimes I just coach them, you know, if it’s easier for you to just say, “Oh, I’m allergic to wheat,” or “I’m allergic to dairy,” or whatever it might be, that is a good response that most of the time will just stop people from pushing food. So, “I’m allergic or I’m intolerant to wheat or dairy” is just a really good out for someone who feels just not quite as strong about coming forward with that, “no” answer.

Melanie: What is really the term fitness bully mean?

Jeannie: When I think about that, I guess it’s--and I would think of it in terms of probably sometimes a dietician, a fitness or even a food bully, if you will, and I view it as somebody who tries to push their beliefs onto somebody else. So whether it’s about food or whether it’s about a specific fitness approach or certain exercises that you should be doing like, “If you want to lose weight or if you’re wanting to build muscle, you should be doing this”. The way that I look at that and, really, what we know, and research supports is that there is not one diet nor is there one exercise regimen that works for everybody. I mean, there’s just not a cookie cutter approach. That can even be a good response to somebody who is trying to push certain foods or certain exercise routines is just that, “Hey, maybe that works for you but I don’t think that that’s going to work for me,” or, “I know that doesn’t work for me,” if they have tried it in the past.

Melanie: Now, even trainers can be fitness bullies if they try to get you to do something you don’t want to do or maybe they’re just talking to you a little bit differently if you’re someone who has a little extra weight. Have you ever experienced that?

Jeannie: Well, I mean, not so much me personally but I certainly have heard some of the clients that I work with talk about that if they have worked with personal trainers and, certainly, wanting them to do exercises that maybe they have had injuries in the past and know that--say, a physical therapist or an exercise physiologist, has said, “That might not be the safest or the best exercise for you to do”. So, again, I think it’s a matter of really advocating for yourself and saying, “Hey, because of a previous injury or because of a medical condition that I have, I’m not able to do that. I know that that doesn’t really work for me or it’s not safe for me to do that.

Melanie: So, you really have to stand up for yourself. What about when you are your own fitness bully because we all, especially women, Jeannie, we negative self-talk ourselves all the time. What can we do to get that out?

Jeannie: Yes, we do. Oh, gosh, I really see this every day and I would see the majority of the people that I work with are women and, unfortunately, there is a lot of negative self-talk out there. So, when I start to hear that from somebody or somebody is aware of it, I think that’s really the first step is that awareness piece. So, if someone doesn’t know that she is doing that, it’s just a matter of gently trying to point out or even just repeat back to her what I just heard her say so she can actually hear it, and ask, “Hey, do you hear the negativity in that?” And so, that’s really the first step, is to become aware of some of that negative self-talk. And then, I tend to use a practice that’s called “reframing”, and really what that does is help somebody to identify those negative irrational thoughts or beliefs that they might have, and actually write them down and then reframe them in a sense into more positive thought or a positive affirmation. I’m a really firm believer in ‘I am’ statements. Another thing that we know is that the brain really works to prove a thought that we have. So, if somebody is saying, “I am lazy,” the brain is going to find ways to prove that’s true; whereas, if somebody has an I am statement that says, “I am fit and healthy,” then your brain is going to work to prove that. So, oftentimes, it’s a matter of having those positive thoughts or affirmations or ‘I am’ statements that a person might not even 100% believe at the time but if they can just start running that through their minds and maybe even putting it on Post-it notes around places that they spend a lot of time just as a constant reminder, as they start to say those things and think those things, it can completely change their outlook. They can start to see positive things happen and focus more on the positive outcomes and be more solution-focused than problem-focused when it comes to whatever area of their health and wellness that they’re wanting to focus on.

Melanie: What a great way to put it. I always like to say to people, be part of the solution, not part of the problem. So, along those lines and in just the last few minutes here, wrap it up for us. What do you do or what do you tell people if they see somebody else body shaming somebody else? And, if they’re in the locker room and they see some women giggling about another woman, do you stand up to them? Do you keep quiet? What do you tell people? Give us your best advice about being your own best health advocate and avoiding those fitness bullies.

Jeannie: I think everybody is different and so they need to know, each person needs to know, their own personality. For some people, it might be actually standing up and saying something. I would certainly encourage doing it in a gentle and non-threatening manner but just to say, “Hey, do you realize that it might take that person a lot of strength and courage to even get in a swimming suit and come to a water aerobics class? Or, to even come to some type of a gym and work out in front of others?” Otherwise, if somebody really doesn’t feel okay that they want to do that, I think it’s just a matter of really turning that within and just saying, “Okay, I want to make sure that I’m not doing that type of thing, and that I want to really encourage and support people that I see here making the effort to either make healthy food choices or to just get here and exercise.” So, I think it’s just giving that kindness and trying to not pass judgment on others. We never know another person’s story and so it’s just trying to have that kind and encouraging demeanor.

Melanie: Really great advice. Thank you so much, Jeannie, for being with us today. You’re listening to The Wellcast with Allina Health. And for more information, you can go to www.allinahealth.org. That’s www.allinahealth.org. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Palliative Care for Metastatic Cancer: Helping You Cope

Additional Info

Segment Number 1
Audio File city_hope/1637ch2a.mp3
Doctors Cahan, Benjamin
Featured Speaker Benjamin Cahan, MD
Guest Bio Benjamin Cahan, M.D., treats patients at our South Pasadena, Antelope Valley, Corona and Arcadia practices. He is trained in all areas of radiation oncology including the latest advances in image-guided radiotherapy, brachytherapy, 3D conformal radiotherapy and 4D computed tomography simulation. Dr. Cahan is a “home-grown” member of our City of Hope family. He joined us as a Resident in 2012 after receiving his medical degree and interning at UCLA.

Learn more about Benjamin Cahan, M.D
Transcription Melanie Cole (Host): There’s more to cancer care than simply helping patients survive. There’s more to cancer treatment than simple survival. Constant pain should not be a part of conquering cancer. My guest today is Dr. Benjamin Cahan. He’s a radiation oncologist at City of Hope. Welcome to the show, Dr. Cahan. I would like to start by asking you, what is metastatic cancer?

Dr. Benjamin Cahan (Guest): Thank you for having me on your program. Metastatic cancer has to do with what happens when cancer spread beyond the initial site of disease. I think we all have a general understanding that cancer arises because of abnormal cells that arise in a normal organ of the body, things like breast cancer which arises in the breast, or prostate cancer which arises in the prostate. Unfortunately, in some circumstances, those abnormal cancer cells leave the organ that they arise from and can spread to other parts of the body. Once they have spread to other parts of this body, this is called “metastatic cancer”. Now, cancer can spread to a number of different sites in the body. We see it spread to lymph nodes; we see it spread to the bone; we see it spread to visceral organs. These all represent different disease states that generally require multiple types of therapeutic interventions to help patients in that setting.

Melanie: People hear the term “palliative care” and right away they think end of life care or hospice but there’s a big difference. Tell us about palliative care.

Dr. Cahan: I think that there is a very common misperception that when a patient is being discussed for palliative care that that means they’re out of options and we’re really just putting them on hospice and really that is far from the truth. In my mind, palliative care, are specifically your first medical interventions, are to help patients with symptoms. So, in the setting of metastatic cancer, for instance, when cancer spreads to other sites, it can cause specific problems. When cancer spreads to bone it can cause pain. When cancer spreads to the gastrointestinal tract, it can result in bleeding that can be difficult to control. So, when I’m speaking of palliative care, I’m really speaking of interventions that are trying to help patients who have those symptoms, patients who are having pain from cancer, patients who are having bleeding from cancer, or other such things. Our primary intervention, at least when it comes to radiation, is to try to make them feel better.

Melanie: Give us some tips for managing cancer pain and keeping it under control. Does the patient have to first quantify their pain? What do you do for them?

Dr. Cahan: That’s a very interesting question. I think we’re all taught vital signs when we go to medical school. I think these are commonly known things, like a patient’s temperature, and their heart rate, and their blood pressure. But, increasingly we’re referring to pain as the fifth vital sign, and you may have seen these scales when you go visit your physician, and we generally try to rank pain on a scale from 1 being “little to no pain at all” and 10 to being “excruciating pain”. So, I think all physicians, particularly in the setting up of metastatic cancer, like to get a good idea of the degree of discomfort that a patient as in. Once we’ve established that the patient is having pain and we understand that this is secondary to cancer, I think there are a lot of different things that we can provide for these patients. In the setting of metastatic disease, the primary backbone of therapy remains systemic treatments. By systemic treatments I mean drugs, for the most past, that try to fight off cancer everywhere in the body. These can be chemotherapy but, increasingly, there are novel agents that target specific mutations or can help the immune system fight off the cancer. However, these systemic therapies are usually not enough, and in the setting of pain, we often rely on radiation therapy which can provide highly focused and highly powerful x-rays that can try to treat the areas of the body that are in pain because of cancer. Of course, regular pain medications, opioid type pain medications, also play a role, and that’s why the understanding of the degree of pain that a patient is in is very important for managing these symptoms.

Melanie: Before we talk about radiation to help with these symptoms, when you mention opioids, people are a little bit afraid of addiction when they have to start taking pain medication on a regular basis. What do you tell them?

Dr. Cahan: I think this is a very common concern. In the popular press, we’re seen an explosion of stories about patients who have been having a very difficult time with chronic pain medications. For the most part, we counsel our patients that people who run into trouble with opioid pain medications are taking them for a very prolonged periods of time for, very often, questionable indications. For people have metastatic cancer, I think our goal is to have them off those pain medications in as short a period of time as possible. For instance, in the setting of cancer that spread to a bone that causes fractures or other discomfort, our hope is that we can start them on opioid pain medications and then shortly thereafter switch them, or decrease the dose of pain medications, or get them off them entirely, because other interventions specifically targeting the cancer can result in them feeling much better.

Melanie: What do you do as a radiation oncologist with radiation and these x-rays you mentioned to help with that pain management?

Dr. Cahan: Radiation therapy, for decades now, has been used for cancers in all sites of the body. What radiation does is it takes highly focused beams of x-ray radiation that cause DNA damage and results in, essentially, the death of the cancer cells. So, while we commonly use it for cancers that haven’t to other parts of the body as part of curative therapy, it remains a vital treatment for patients when the cancer has spread to other places. So, certainly, the most common thing we see is that cancer has spread to a bone somewhere and causes pain. This will generally result in a referral to a radiation oncologist who will see a patient in consultation. After consultation, we would begin radiation therapy. In general, there are two steps of radiation. Before you can deliver the radiation, you have to make sure that we’re targeting our beams of x-rays to the exact correct anatomic location. So, this requires the CT scan. It’s a scan that we call a CT simulation. A patient comes in, we have them lie in a particular position, we get a CT scan, and then we send them home. In the next couple of days, we need to do some calculations to design a radiation treatment plan that specifically targets the area that’s causing the patient’s symptoms. After a couple of days, they come back and begin radiation therapy. Radiation therapy for palliative purposes can be done in a very few number of treatments. Occasionally, we can treat patients in a single day of radiation therapy. Sometimes it requires daily treatment for up to 10 to 15 days. But, nonetheless, we try to keep the treatment as short as possible because, again, our primary intent is to make them feel better and improve their quality of life.

Melanie: Just to be clear, this is not helping to get rid of their cancer, this is strictly palliative, to help for that pain in their bones that has spread.

Dr. Cahan: Certainly, to get rid of the cancer everywhere in the body is not the intent of the radiation therapy. It really is focused on certain areas where they’re having pain. Now, we do eliminate some of the cancer cells in those areas, but we’re not targeting the cancer that can be everywhere else in the body, yes.

Melanie: Do people worry about the amount of radiation due to this type of therapy?

Dr. Cahan: Again that’s a common question that we get. There is always concern when we expose patients to ionized radiation and the primary concern is that we know that radiation exposure can contribute to a second cancer being caused sometime in the future. In general, the time period to get a second cancer from exposure to radiation—and by this I mean x-rays or radon when you fly in an airplane—can be quite a long period of time. It can take a 8, 10 years, or even longer to see a cancer formed and even those rates are extremely small. For us, we’re dealing with a patient with an acute need right now and our primary intent is to help them feel better in as short a period of time as possible.

Melanie: If it’s spread to the bones, is it hard to narrow down where it is? You mentioned the CAT scan, but what if it’s in many different areas? Then, do you radiate that many areas, or do you pick one spot where the pain is more severe than others?

Dr. Cahan: In general, when we see patients with cancer spread to multiple, multiple sites in the body, it’s difficult to provide radiation to essentially the total body. What we try to do is combine imaging, and by imaging that can mean CAT scans, but there’s other forms of imaging--PET scans and bone scans and other things--that can help us delineate where the cancer is. But, we also need to do a clinical and physical exam. We need to see a patient in an exam room and touch them and lay hands on them and try to figure out where exactly is the pain coming from and really limit our fields of radiation to target the areas that we think are causing the symptoms.

Melanie: Does this weaken the bones as a result, and is there an adjuvant therapy that goes along with that?

Dr. Cahan: It actually weakens the bone that is having cancer in the bone. So, we often think that the cancer you can think of like moths chewing up your clothes and these cancer cells are going into the bones and chewing it up actively. Now, bones try to heal themselves, but they are unable to heal themselves while the cancer is actively destroying the bone. So, in the process of eradicating the cancer in the local area, that allows the bone the opportunity to try to heal itself. We do know that radiation therapy can locally weaken the bone somewhat, but the doses we give in these palliative settings should not cause significant long-term harm. However, in general, we should continue to do good bone health, which requires visits with primary care physicians or medical oncologists and simple interventions like vitamin D and calcium are often recommended for all of our patients.

Melanie: Wrap it up for us, Dr. Cahan. It’s really amazing information on what you do. We applaud all the great work that you do. Wrap it up about palliative care for metastatic cancer and why they should come to City of Hope for their care.

Dr. Cahan: When it comes to cancer that’s spread outside the initial site of disease, when it comes to metastatic cancer, we are really in an area where we need all physicians on board. This is a true multidisciplinary effort. It requires radiation oncologists because we can provide a very local therapy, but it also requires world class medical oncologists who know the best systemic therapies that could help manage the patient’s disease. It requires social workers and therapist and psychosocial workers because there’s a lot of difficulties in family interactions that really all need to be brought together to provide the best type of care for our patients. Occasionally, our patients need surgery in the setting of metastatic cancer as well. So, one of the unique and special things about City of Hope is that we can bring world-class experts from all of these fields together to bring the full weight of all of our skills to try to provide the best possible care for our patients in these settings.

Melanie: Thank you so much for being with us today. You’re listening to City of Hope Radio. For more information you can go to www.CityofHope.org. That’s www.CityofHope.org. Thanks so much for listening.
Hosts Melanie Cole, MS

Keeping Kids Safe in the Car

Additional Info

Segment Number 2
Audio File virginia_health/1635vh4b.mp3
Doctors West, KK
Featured Speaker KK West
Guest Bio KK West is a safety program coordinator at UVA Health Systems.

Learn more about UVA Children’s Hospital
Transcription Melanie Cole (Host): Selecting a child’s car seat can be overwhelming for families. My guest today is K.K. West. She’s a safety program coordinator for UVA Children’s Hospital. Welcome to the show, K.K. What are some of the different types of car seats and what ages and sizes should they be used?

K.K. West (Guest): Okay. There are several different car seats on the market today. We have the rear- facing infant car seat which sort of looks like or is familiarly known as the “bucket car seat” which is used really just for infants. The height and weight limits for the car seat set the tone for the car seat. So, when the child has reached the height and weight limit for that infant car seat, at that point, they would want to either move to a convertible car seat which also can be rear-facing or forward-facing. The infant car seat has a five point harness in it. The convertible car seat is rear-facing and once the child reaches about age two or has outgrown the rear-facing guidelines set by the car seat manufacturer, at that point, that seat would turn around and become forward-facing. Then, forward-facing only car seat would be a car seat that is designed just to be forward-facing. Those car seats can have the five point harness and some for them do convert into a booster seat which has the lap and shoulder belt. Then, there are the booster seats which is the car seat that is designed just for a lap and shoulder belt. Typically, that is for children ages four through eight as long as they meet the height and weight requirements for the seat.

Melanie: So, that’s where parents need to look--at the height and weight--because some children, mine included, are tiny or don’t fit that height and weight requirement. So then, do we keep them in longer?

KK: Yes. The American Academy of Pediatrics is recommending that all children stay rear-facing for at least age two, and longer if they still fit the height and weight requirements of that rear-facing car seat. The idea behind that is that children’s head and neck muscles are not as developed as adults or an older child, so keeping them rear facing would keep them safer longer. Then, once the child is large enough to be forward-facing and is in that five point harness, then you would continue to monitor your child’s height and weight based on what the seat manufacturer has established for the seat.

Melanie: So, what should families look for and keep in mind when they go out shopping for those car seats? There are so many on the market?

KK: It’s overwhelming what’s on the market. So, there really isn’t a set, “Oh, this is the best car seat.” When you go out shopping for a car seat, you have to keep lots of things in mind. One, which car seat best fits your family’s need? If you have three children, you may need a more narrow car seat to fit the three car seats across the back of your car. If your child is a larger built child, you may need more of a convertible car seat versus the infant car seat. So, the rule of thumb is, you want to look at your child’s specific need, which car seat actually fits in your car and how many car seats you will need. So, if you drive a sports car, for example, a large, huge convertible car seat may not fit as easily as a different convertible car seat. So, it’s really about what works best for your family, your car.

Melanie: And, you really have to look at the size of your car, the size of the seat and the thought of your back--putting a child in there.

KK: Correct, absolutely. All car seats are crash tested to the same guidelines. So, when you’re looking at car seats, it really does matter which car seat best fits the child, best fits the car, and best fits your lifestyle.

Melanie: Now, tell us about the risks of using used or expired car seats. People tend to say, “Oh, I've got one you can use. Don’t bother going out to buy one.”

KK: Well, the car seats spend a great deal of time in a car. Cars get really hot, cars get really cold. So, when they set guidelines for expired seats, they’re doing it because the integrity of that plastic and the seat material, after so many years of being out in the heat, the sun, the cold, can start to break down. If you think about a plastic chair that sits on your deck and after years of sitting out there, eventually the plastic gets old and brittle. The same thing is true for car seats. You want to make sure that your car seat is safe. So, many car seats have a five year lifespan on them. Others have a little bit longer and it should say on any of the car seat, the “best used by” date on the sticker on the side of the car seat.

Melanie: What is the LATCH system?

KK: The LATCH system stands for “lower anchors and tethers for children” and all cars and car seats that came out after 2002 have this new system. What it is, is in the cars, there are little metal rings that are built into the base of the seat, and then there’s a LATCH system that’s hooked in. Sometimes it’s on the back of the seat. It’s a way for families to be able to get a child seat securely in the car without using a seatbelt system. It’s supposedly easier to install than just a secured seatbelt system although those work. The things about LATCH systems is that each vehicle has its own weight limit for the LATCH system and so it’s important that you check with your vehicle manufacturer and make sure that you monitor your child’s weight. Once your child reaches the max weight for that LATCH system, they would then need to use the seatbelt as the means to anchor their car seat.

Melanie: And, when is a child ready to ride in the vehicle using just a seatbelt? Is that based on height, weight, one or of each of them? What if they don’t match up?

KK: All of the above. So, the recommendation now is that eight and above is a general age timeframe but, really, it’s about the size of the child because some eight-year-olds are teeny tiny and some eight-year-olds are big. So, the way that you can assess that is if the child’s bottom fits up against the back of the seat with their back against the back of the seat and their knees are bent easily over the edge of the seat with the feet touching the floor, flat on the floor. The shoulder belt needs to fit across the shoulder and not at the neck and the face and the lap belt needs to fit not across the belly or stomach area but across the thigh area.

Melanie: So, if it’s coming up over by their neck, they are too small to be sitting in that seatbelt.

KK: Absolutely. Yes. So, many of the booster seats now have increased their height and weight for them. So, some of the booster seats actually go up to 100 pounds.

Melanie: So, what if your kid fights you on that?

KK: Then, you work on more of a behavioral and a car seat plan. My son absolutely did not like riding in his booster seat but he wasn’t quite tall enough to come out of the booster seat yet. So, we remind them of the safety and how important it is, and we encourage them that the car didn’t go until everybody had their seatbelts on and he was in his seat. And then, we routinely checked his size to make sure that when he reached that point that he could come out of his car seat.

Melanie: So, wrap it up for us, K.K.. It’s really great information. It’s so important for parents to hear from an expert such as yourself about why this is so vital to follow these instructions. So, wrap it up with your best advice on car seat safety.

KK: Okay. I am going to say that all children under the age of 13 should ride in the back seat of the car. I’m going to add that little plug. So, if you are 12 or younger, you really should ride in the back seat of the car. All passengers in a vehicle should be restrained. There was an old rule of thought that once you were in the backseat, you didn’t necessarily have to have your seatbelt on and that’s not true. Set the best example. As a parent or as a guardian, when you get in the car, put your seatbelt on and that’s going to help remind the children that it’s important for them to wear their seatbelts, too. So, modeling that good behavior. The other thing that I would say is car seats should be replaced after a moderate to major crash to ensure that that child is safe. A crashed seat may not be able to provide the safest environment for that child.

Melanie: Thank you so much for being with us today. You’re listening to UVA Health Systems Radio. For more information you can go to www.UVAhealth.com. That’s www.uvahealth.com. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Race Recovery: Important Tips

Additional Info

Segment Number 1
Audio File virginia_health/1635vh4a.mp3
Doctors Hryvniak, David J.
Featured Speaker David J. Hryvniak, MD
Guest Bio Dr. David Hryvniak is a physician in the Department of Physical Medicine and Rehabilitation (PMR), and an avid distance runner.

Learn more about Dr. David Hryvniak
Transcription Melanie Cole (Host): Knowing how to recover from an endurance event is just as important as knowing how to compete. My guest today is Dr. David Hryvniak. He’s a physician in the department of physical medicine and rehabilitation at UVA Health Systems and at the UVA Runners Clinic. He’s also team physician for UVA athletics. Welcome to the show, Dr. Hryvniak. Let’s talk about first race day. Before we talk about recovery, I’d like to talk about event day. To plan for a good event, what would like them to do the day of, when they wake up in the morning before a long race or any event?

Dr. David Hryvniak (Guest): I really think it begins during your training. Really, preparing for a race is you have to practice everything. You’re not only practicing the running in that aspect, but you want to practice your eating. You want to practice the things you will be eating during the race as well as pre-race, so that way you don’t get any GI disturbances during a race. You also want to practice hydrating as well. And you want to have a routine down prior to the race. I always tell people, “You don’t want to try anything new on race day, whether that be shoes, what you’re eating or what you’re drinking.”

Melanie: Are there some things you like people to eat and/or drink on race day that will help them get to the end of the event and recover faster?

Dr. Hryvniak: It certainly depends on the event that you’re going to be doing. The typical carbo-loading that many people did before racing doesn’t have a whole lot of literature to back it up, but a lot of people find that the pasta and carbohydrates are easier on the stomach, so most people can tolerate that. I always say, “Find something that works well for you the night before as well as the morning of.” And, if it’s going to be a hot race you really need to make sure you’re hydrating before the race. We want you using both sports drink as well as water and making sure that you’re topped off before you begin the race.

Melanie: You said sports drinks as well as water. Is there a time when one is preferable over the other?

Dr. Hryvniak: I find that if it’s going to be really hot, I prefer sports drinks, because you’re getting some electrolytes in that mixture. There is a risk of people overhydrating, especially if they’re just drinking water, and there’s such a thing that we worry about in the marathon medical finish tent at some of the marathons we cover, it’s called “hypernatremia.” That’s where people basically dilute out their salt because they drink too much water during the race and before the race. So, I always find a mix of both sports drink and water, and mixing those up, is the best to prevent that.

Melanie: Is there anything people can do to limit the soreness during an event that’s going to occur after recovery. Is that only based on their training?

Dr. Hryvniak: Some of it has to do with training. Some of it has to do with making sure that you’re properly fueled beforehand. And then, as we’ll talk about a little bit later, with recovery, there are certain things that we can do to help limit delayed onset muscle soreness immediately after the race as well as that evening and in the following days and weeks as you recover from the race.

Melanie: What are some of those? Let’s get to the recovery part of it and what can you do? Let’s just start with soreness and musculoskeletal issues that might happen if you’re feeling knee pain, if you’re feeling a little swollen, maybe you’ve built up a little water retention, or you know you’re going to feel sore. What do you want people to do? Do you want them to stretch? Do you want them to sit right down? What do you want them to do?

Dr. Hryvniak: I usually break it down into immediately post-race and then that evening and the following day. So, immediately post-race is as soon as you cross the line, the thought is everyone wants to stop. You’ve finished your marathon, you want to stop, but the best thing to do is continue to walk around for 10-15 minutes because that’s going to help get rid of some of the waste products including lactic acid that’s in your legs and allow your body to use those muscles that you have to pump that out of your muscles. If it’s a shorter race, some people like to do a cool down jog, so a 10-15 minute real slow jog. Along the same lines, we’re trying to get all the waste products out of their legs. I find immediately post-race, that’s the best thing to do for the first 15-20 minutes after you finish.

Melanie: If you’re feeling knees and ankles and such, do you like them to ice once they’ve done their walking around for a while?

Dr. Hryvniak: Either using ice directly to the joint or an ice bath is very helpful for people. So, usually we recommend that after an event or after you’re done cooling down, doing it for about 10-15 minutes at a time, you don’t want to do it much longer than that. You can either create an ice bath at home and put some ice in your bathtub and sit in there for 10-15 minutes and really ice down all your legs, or you can specifically put an icepack on that joint. But, ice is very helpful. I do caution people to not use anti-inflammatories like Advil or Aleve immediately post-race because that can sometimes have its effects on your kidneys. So, I ask people to avoid using that immediately after the race, even if they’re having some joint aches or pains.

Melanie: Dr. Hryvniak, you are an avid distance runner. Have you ever taken an ice bath? How uncomfortable are those?

Dr. Hryvniak: We used to do them after every workout. I ran at the College of William and Mary, and three times a week we would take ice baths. Some of my teammates would do it more often. It is an uncomfortable feeling until you get used to it. But, if you’re not an avid person who likes to sit in the cold, it’s definitely difficult in terms of handling that cold. But, I would usually read a magazine or a book or watch TV and that seems to help take your mind off of it.

Melanie: Tell us about your long distance runs.

Dr. Hryvniak: I ran in high school and college and then through med school, I continued to race at the marathon and the half marathon distance. I run four our local post-collegian Olympic training team, it’s called the Ragged Mountain Racing Team here in Charlottesville. We have had several people qualify for the Olympic trials this year. I’m still trying to continue to run well at the marathon and on the road.

Melanie: That’s fantastic. What about food and beverages after a race? Now we’re hearing more and more about chocolate milk and you mentioned energy drinks. So, what do you want people to do just after as far as nutrition?

Dr. Hryvniak: There’s really an ideal window. I usually tell people 20-40 minutes after you finish activity is the ideal window when your body is going to absorb the most nutrients and allow you to recover the best. So, I always tell people, “Let’s get some kind of carb, protein and fat in during that period of time.” I usually say do a 3:1 ratio in terms of carb to protein, so something like chocolate milk that has some carbs in it, sugars, as well as it has some protein and fat, is really an ideal post-race drink. Several companies make other kinds of recovery drinks that have similar types of ratios in terms of the carbs, protein and fat. But, even just some sports drinks will get you at least the carbs in if you can’t tolerate the chocolate milk. It’s really important to rehydrate after a race. Especially hot races, we need to replenish our weight loss. It’s not uncommon to lose a couple to a few pounds after a hot race. So, we really want to replenish that weight loss because that is all water loss in terms of that weight, and replenish our electrolytes. So, using some water as well as an electrolyte type drink, like a Gatorade or PowerAde is useful for that.

Melanie: What about the protein drinks, Muscle Milk and such? People think if you drink these really high protein drinks, 30 grams, 40-50 grams, that it goes right to your muscles and helps them replenish.

Dr. Hryvniak: You want some protein, but what I find is that can upset people’s stomach, especially post-race, and it’s very difficult to absorb that much protein in a short span of time. So, really, you only end up absorbing some of that and the rest of it is wasted. So, I think finding that perfect ratio, and the literature shows us that 3:1 ratio. You really want to be replenishing your carbs because that’s what your body is predominantly burning, that and glycogen when you’re racing. The protein will help with muscle building and recovery in terms of that. Then, we actually use some fat when we do endurance racing as well, so we want to replenish some of that as well.

Melanie: In the last few minutes, tell us about the emotional impact of finishing a major race, Dr. Hryvniak. People want to feel that high. They want to feel that satisfaction in knowing that they did something. What does it feel like?

Dr. Hryvniak: It’s exciting when you finish your first marathon or your first race and you cross the finish line. And then, there’s a little bit of a letdown, because you’ve trained for this event for months and months and now it’s done, and a lot of people are like, “What do I do next?” I’ve found in the past, at least finishing, I think I’ve finished at least 15 marathons, that the first hour or so after the marathon, you hate the event, and then about an hour later you’re looking for the next one. So, there’s definitely a certain amount of motivation to look for your next race after you’re finished but you have to be careful and give yourself a break. I always recommend people make sure they get good sleep that night, take advantage of those free post-race massages that they have at a lot of races. If they don’t have that, do some foam rolling after. And then, for the next several days, especially after a marathon, really make sure you’re resting, retouch with your family, do some things that you weren’t able to do during your training cycle to refresh your mind. And then, you can begin training for your next event.

Melanie: Just tell us about the UVA Runners Clinic at UVA Health Systems.

Dr. Hryvniak: We are the only clinic in the area that is for runners and we are staffed by runners. So, all our physicians are experienced runners and we’re all board certified in sports medicine. Our goal here is we don’t like to tell people that they have to stop running, so we like to get people back out on the roads and will use different tools to help diagnose injuries and get people back on their feet. So, we use gait analysis and customized rehab programs. We’ll make a return to run programs for people coming off an injury or a long break off running. Our enjoyment comes from getting people back out there and able to compete. We also cover a lot of the local races, high school, college and a lot of the local road races, including the men’s 4-miler or women’s 4-miler, the Charlottesville 10-miler and the marathon, which are all major events here locally.

Melanie: Thank you so much. What great information, Dr. Hryvniak. Thank you so much for being with us today. You’re listening to UVA Health Systems Radio. For more information you can go to www.uvahealth.com. That’s www.uvahealth.com. This is Melanie Cole. Thanks for listening.
Hosts Melanie Cole, MS

Do You Need Spine Surgery?

Additional Info

Segment Number 2
Audio File corona/1634cr5b.mp3
Doctors Lin, Richard Y.
Featured Speaker Richard Y. Lin, DO
Guest Bio Dr. Richard Lin is a Spine Surgeon and a member of the Medical Staff at Cornona Regional Medical Center.

Learn more about Dr. Richard Lin
Transcription Melanie Cole (Host): Spine damage can cause pain, numbness, and muscle weakness that can make everyday tasks difficult. The spine program at Corona Regional Medical Center offers non-surgical and surgical treatment options to help you return to an active life. My guest today is Dr. Richard Lin. He is a spine surgeon and a member of the medical staff at Corona Regional Medical Center. Welcome to the show, Dr. Lin. What are some of the most common spinal issues that you encounter every day?

Dr. Richard Lin (Guest): I think that some of the most common spine issues that I encounter on a daily basis is primarily due to normal wear and tear of the spine, referring specifically to osteoarthritis which causes the space to collapse and overgrown growth joints to develop that causes impingement on a certain neural element within the spinal canals, such as either the spinal cord or the nerves that are branching off directly from the cord, or from the thecal sac. Typically, when this happens patients will present primarily with symptoms descriptive of low back pain that radiates down to the legs and sometimes into the toes. In addition to that, sometimes it could also present with numbness and weakness depending on how far along in their disease that they are.

Melanie: When someone comes to you, what's the first line of defense that you do for them?

Dr. Lin: The first thing you do is you get a good history, and you talk to them and say, “Hey, do you have any weakness? Tell me more about the pain. How far down the leg does it go?” It then gives you the idea exactly of where the issue is in the spine. You start with some x-rays. X-rays can't see nerves, it can't see muscles, it can't see ligaments, it can't see much at all. The only thing you're able to see is anything that's calcified and, specifically, what you're looking at is the spinal column as a bulk. One of the most useful things in the x-rays is that you're able to evaluate for stability of the spine. What I like to do is, I like to get three views, and I shoot a view from anterior to posterior, which is basically front on, and then another one from the side with the patient flexed forward and then another one with them extended backwards. What that does is, it tells me if any vertebral bodies that are out of the alignment. That’s a condition called “spondylolisthesis” which, most of the time, it occurs in arthritis. The joints get worn out and so the vertebral segments lose their stability. Then what happens is that when that bone slides out of alignment, it causes problems to the nerves.

Melanie: So then, when do you tell the patient that it's time to consider some sort of a surgical intervention?

Dr. Lin: Really, it depends on if the issues are in the neck or if the issue is in the low back. In the case of patients who are presenting with leg pain, which is usually it's the low back, then I typically like to exhaust all conservative measures before indicating the patient for surgery, meaning have they tried anti-inflammatories? Have they been through physical therapy? Have they tried to modify their daily activities? And, the last thing is that, what I do is, if they tried all that and they still have this pain down their leg that they consider intolerable, then what I do is, I send them to a pain consult to the pain doctor, for an injection of lidocaine and steroids targeting the nerve and see if that is able to temper down their pain. In some cases, patients get injection and then, I never see them again for years. In other cases, the injection works for six months, they go for another one, that lasts for two months, and they go for a third one and then that lasts for about a week or two. At that point, you tell yourself that the injections are presenting with diminishing returns and, at which point, you tell the patient, "Listen, we've already tried everything. If you don't want to continue to live with this pain, then I would recommend surgical intervention." Now, if they're presenting with weakness, then you present to them the option that, “Hey. This weakness may get worse. If I do surgery on you, the main purpose of the procedure is to prevent further decline of your motor strength. If the surgery is successful, you may get some strength back, you may not, because nerves are a little bit hard to predict." Weakness will be an indication for surgery in the case where they have progressive weakness. Where it's day one and they're having a little bit of weakness when they are lifting their feet off the ground when they walk and day two, they're not walking any more then that's an indication for immediate surgical intervention. In the case of the neck, usually when there's a nerve being pinched in the neck, it could be, given the location, it could be more dangerous because of the spinal cord is there and because it's very high, it affects everything downstream. So, if a nerve is being pinched in the neck. It can, theoretically, affect the leg, and, in that case, your threshold to pull the trigger and bring this patient to the OR for decompression is a little bit lower.

Melanie: Can these surgical interventions be done minimally invasively?

Dr. Lin: Absolutely. Absolutely. There are some new approaches. Traditionally, for the lumbar spine of the low back, we have to instrument patients and fuse them, either going up in the back or going up in the front, both of which involves a pretty reasonable healthy-sized incision and a significant amount of blood loss. With a new procedure called “XLIF,” which stands for “extreme lateral interbody fusion” which we go in from the side, and we make two small incisions, probably about maybe an inch and a half each, and we dock down off the spine from the side. There's not a whole lot of tissue dissection, and we go through the muscle called the “psoas.” We slide the nerves out of the way and we go in and we take out the disk at a specific level, put in a cage. Some surgeons will even put a plate on and put a couple of screws in and that's their fusion, right there.

Melanie: How fascinating. Now, the XLIF cannot be used for all types of lumbar conditions, correct? For ones that are a little bit lower down?

Dr. Lin: Correct. Absolutely. You're right on that. It depends on where in the country you're serving, but a lot of people that do XLIF, they won't go down to L-4, L-5 because that is considered a more dangerous level because it's difficult. The reason what makes it difficult is that, the iliac crest is there and sometimes that blocks to the entrance to the L-4, L-5 disc space, and, in addition to that, the nerves of the lumber plexus are more at risk at L-4, L5 level. However, there are a lot of guys who are very experienced in this procedure that can do an L-4, L-5 and get it done in twenty minutes and, really, there are no complications.

Melanie: Dr. Lin, we hear the word “stenosis” all the time. It's kind of the catch all term, and so many millions of Americans suffer from lower back stenosis, lumbar spinal stenosis. What do you tell them every day when they come to you for back pain?

Dr. Lin: I tell them that, for whatever reason, and I usually blame it on arthritis, that their spinal canal is smaller than what it needs to be and there's just not enough room for the nerves. And so, there's pressure on the nerves, the nerves are flaring up and that's why they have their pain and sometimes their weakness and numbness down their leg.

Melanie: In just the last few minutes, what should people with spinal issues think about when considering spinal surgery or seeking care?

Dr. Lin: Anyone that suspects that they have issues with their spine, and spine issues primarily present, again, with leg pain. It's not necessarily back, it's leg pain that really causes my ears to perk up when I'm talking to a patient. If they suspect that they have this burning feeling down their leg and it's bothering them, then they should go and see their physician about it and, hopefully, get a referral to a reliable spine surgeon. As far as considering whether or not to have surgery, really, the answer is and that I present to the patient is, “Can you continue living with this pain?” If they say, "It's tolerable. It doesn't really bother me. It flares up every now and then." Then, I say, "You know what? Let's ride it out. Let's try some medications. Let's try some physical therapy and let's see how you do." If, however, they say, "I can't sleep at night. I can't function during the day because I can't concentrate. I'm too tired,” or “I'm in too much pain. I've already tried everything. This pain is driving me crazy." Then, it's time to have surgical intervention. The reason why you want to wait it out to the point where you really don't have any choice is because spine surgery is dangerous. I mean, with it comes a lot of possible bad complications.

Melanie: Why should they come to Corona Regional Medical Center for their care?

Dr. Lin: We have a good staff over at Corona, and I think that's really what counts at the very end. The nursing staff, in my opinion, is second to none, number one; and number two is the OR. The facility is great and they have dedicated rooms set up just for spine and specific instruments, they are available there just for spine. On top of that, there are some great spine surgeons there, and the guys that I work with, they make sure that the cases are truly indicated, and that the patient really has no other option other than to undergo surgery before indicating them.

Melanie: Thank you so much, Dr. Lin, for being with us today. You're listening to Corona Regional Radio with Corona Regional Medical Center. For more information, you can go to www.coronaregional.com. Physicians or independent practitioners who are not employees or agents of Corona Regional Medical Center, the hospital shall not be liable for actions or treatments provided by those physicians. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

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